Brit. J. vener. Dis. (1974) 50, 232

Alfred Fournier, 1832-1914His influence on venereology

M. A. WAUGHDepartment of Venereology, West London Hospital, Charing Cross Group of Hospitals, London W6 7DQ

It is now almost a hundred years since Fournier,much against the standard belief of the times,proposed that syphilis was the likely cause of tabesdorsalis. Alfred Fournier (Fig. 1) was unquestionablythe foremost syphilologist in France in the last30 years of the 19th century, but his life and worksare little known in English-speaking countries,probably because so few of his works have beentranslated into English (Fournier, 1906) and becausehe is overshadowed on this side of the Channel byhis contemporary Jonathan Hutchinson (1828-1913).

FIG. 1 Alfred Fournier (from Darier, 1915). Bycourtesy of the Wellcome TrusteesReceived for publication October 9, 1973Based on a paper read to the M.S.S.V.D. in Brussels on May 26, 1973

Alfred-Jean Fournier was born in Paris on May 12,1832, into a family with a medical background. Heexcelled at school at the Institution Jauffret, at theLycee Charlemagne, and the Concours General,throughout which he developed a love for theclassics and humanities. In later years he translatedthe works of John of Vigo, Jacques de Bethencourt,and Fracastorius into French.He began his medical studies on December 22,

1854, and by one of those happy chances of fatefound himself attached in his first year as an internto Ricord at the H6pital du Midi It will be remem-bered that Ricord (1838) had thrown out JohnHunter's erroneous ideas that gonorrhoea andsyphilis were part of the same disease. He alsodivided syphilis into primary, secondary, andtertiary stages and was credited with a vast numberof risquds bons inots and anecdotes (Ricordiana). Hewas aptly described by Oliver Wendell Holmes as'the Voltaire of pelvic literature-a sceptic as to themorality of the race in general, who would havesubmitted Diana to treatment with his mineralspecifics and ordered a course of blue pills to thevestal virgins'.The relationship which developed between Ricord

and his pupil Fournier was to prove one of the mostsuccessful and fruitful ever to occur between medicalteacher and student, the latter inheriting Ricord'sprivate practice, marrying his daughter, and acquiringmany of his master's talents for oratory, teaching,and clinical ability. Fig. 2 (opposite) shows themtogether over 30 years later.

Fournier's first work 'Recherches sur la contagiondu chancre' was published in 1857, and like hissecond major work ('De la contagion syphilitique',1860), which was part of his doctoral thesis, wasdedicated to Ricord. In those days, before thespirochaete had been discovered and when theWassermann reaction was as yet unknown, his thesis,like many works on syphilis of that period, describesvarious types of chancre and early syphilitic eruptionswith their supposed prognoses. It is interesting to

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Alfred Fournier, 1832-1914 233

F I G. 2 Fournier with Ricord and Hardy at theFirst International Congress of Dermatology, Paris,1889 (from Gougerot and Brodier, 1932)

note the motto, Quod vidi, scripsi, which appeared on

the title page of the work of 1860.In 1913, a year before his death, the Bibliotheque

Nationale had listed 92 publications by him inFrance. Proksch (1889 and 1900) listed even more

works, including all his articles in learned journalsboth in France and abroad.

After 1860, his career rapidly advanced. He wrotea thesis on uraemia (1863) for his agregation; thenhe became involved under Jaccoud in work on

gonorrhoea, and declared in 1866 that it was a

quite separate form of urethritis from that which hedescribed as simple (presumably non-specific) ure-

thritis, saying that the former was caused by a

specific virus. Of course N. goniorrhoeae was notdescribed as a microbe peculiar to gonorrhoea until1879 when Neisser used Koch's staining methods.One fallacy that Fournier believed was that onlyblennorrhagic (i.e. gonococcal) urethritis could cause

rheumatism. His contemporary Emile Vidal (1825-1893) was to describe keratoderma blennorrhagicain 1893.From 1868-1876 Fournier was chef de service at

the H6pital de Lourcine, and then until 1880 at theH6pital Saint Louis, the great hospital for diseases

of the skin in Paris. Throughout this time of la belleepoque, he gained vast clinical experience of theravages of syphilis. He later declared how he pitiedthe poor public patients who had to give all theirclinical details in the vast open out-patient depart-ments of the times.

In 1873 appeared the first edition of 'Lecons surla syphilis, etudiee plus particulierement chez lafemme'. In the Annales de Dermatologie et de Syphili-graphie for 1875-1876, he put forward in two articlesthe idea of a syphilitic origin for tabes dorsalis(Fournier, 1875). His propositions were that syphiliswas a cause of the symptoms of paralysis, motorincoordination, and progressive locomotor ataxia,and he divided the disease into types affecting thelumbar, cranial, and optic nerves. He showed that,of thirty cases of tabes dorsalis, 24 had a definitesyphilitic history-24 fois sur 30, voyez quelle pro-portion.

These findings, coming from a venereologist,caused much consternation, this being the time whenCharcot presided over the school of neurology at theSalpetriere. In fact, Charcot never came round tobelieving that syphilis was the cause of tabes dorsalis.Other eminent neurologists took sides. Westphal(1880) said it was not proved, but also that it was notprobable that syphilis was the cause of tabes. Gowers(1892) added a cautious note, stating that 'tabes isgenerally although not invariably a post-syphiliticdisease'. Erb became Fournier's most strenuoussupporter and, from a vast study of 1,100 male casesfrom the upper classes, with 10,000 controls, showedthat 89-5 per cent. of patients with tabes dorsalishad had a chancre or definite syphilis (Erb, 1892).Fournier formed the concept of parasyphilis, i.e.'those diseases of which syphilis is essentially thecause, but which are not directly the result of thesyphilitic virus, namely general paralysis, tabesdorsalis, tabo-paresis, and primary optic atrophy'(Mott, 1910).

'La syphilis du cerveau' (1879) gives excellentillustrations of epilepsy in tertiary syphilis, foliesyphilitique, and the excitement and mania of generalparalysis, with a beautiful description of the hand-writing of patients with that disease.Throughout this time Fournier built up a card

index of 50,000 cases which were to be the sourcematerial for all his writings.

In 1879 Fournier was elected a member of theAcademy of Medicine, and it was only natural that in1880, when a clinical chair of dermatology andsyphilology was set up in the faculty of medicine,it should go to Fournier who was to hold it until1902. He was a teacher with an impressive presence,immaculately dressed with the ribbon of the Legion of

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234 British Journal of Venereal Diseases

Honour in the buttonhole of his frock coat, andalways courteous to both patients and pupils. EveryTuesday saw the presentation of cases and everyFriday he gave his professorial lectures, on whichmany of his books were based. He wrote threeother works devoted entirely to the neurologicalaspects of syphilis; 'L'ataxie locomotrice d'originesyphilitique' (1882), 'Lecons sur la periode prae-ataxique du tabes d'origine syphilitique' (1885),and 'Les affections parasyphilitiques' (1894), bywhich time his views on the syphilitic origin of tabesdorsalis and general paralysis of the insane wereuniversally accepted.

Apart from his writings on syphilis, Fournier alsoproduced papers on dermatological subjects, suchas the cutaneous manifestations of diabetes mellitus,vacciniform herpes in infants, and eruptions due toantipyrin.To list all his books on syphilis would be to give

no more than a mere catalogue. The chief ones havebeen described by Gougerot (1932). After Diday andHutchinson, Fournier did more than any otherclinician to develop the subject of congenital syphilisand he brought order out of chaos. From 1857 to1863 Hutchinson had described in detail in severaljournals all the entities now known as Hutchinson'striad. At the same time Diday and Parrot were theforemost French workers in the field of congenitalsyphilis. However, it was left to Fournier in 1886 in'La syphilis hereditaire tardive', to coin the phrase'Le triad de Hutchinson'. The next year Hutchinson(1887) dedicated his book 'Syphilis' to AlfredFournier, 'as a small expression of friendship andhigh esteem'. In 'Traitement de la syphilis' (1894),may be found Fournier's aphorism for treatment,'a maladie chronique, il faut traitement chronique'.'Les chancres extra-genitaux', written in 1897 withhis son Edmond Fournier, contains classic descrip-tions of every extragenital chancre.

In 1899, again with the collaboration of his sonEdmond, he wrote his 'Traite de la syphilis', thequintessence of his whole life's work. It was trans-lated into English, and an edition was published inNew York.

Fournier had far more influence on venereologythan his immediate work and teachings. He statedthat venereology was as much a specialty as anyother and that it took 10 years to train a consultant.He abhorred the fact that medical students couldqualify knowing next to nothing about venerealdiseases. He tried to improve the general level ofundergraduate medical teaching in venereology, butin his own times, with little success. He pointed out,as have others since, what a wealth of teachingmaterial was to be found in the Lock hospitals.

He was immensely sympathetic to the innocentfemale sufferer from syphilis and claimed that inhalf of his female syphilitic patients with tertiarymanifestations he was unable to obtain any historyof infection. From his early days at the Lourcine hehad seen how syphilis affected the wives and ulti-mately the children of the male syphilitic. He notedwhat a terrible effect it had together with tuber-culosis and alcoholism on the whole country, causinghigh infant mortality, chronic ill health, wastage ofman-power, and personal disaster.From his vast experience of the ravages of syphilis

he decided that the medical profession as a wboleand not just specialists must be aware of the dangersof venereal disease, and also that the intelligent lay-man must be informed. In 1901 he founded the'Societe francaise de prophylaxie sanitaire et morale',devoted to spreading knowledge to combat syphilis.

In this work, the play 'Les avaries' (DamagedGoods) by Eugene Brieux (1902) had great influence.It was dedicated to Fournier, and tells how a younglawyer infected with syphilis declines his physician'sadvice to take a long course of mercurial treatmentand postpone his marriage. The young wife and theirson and the child's wet-nurse become infected andfamily misfortune follows. Of course, in the mannerof melodrama of that period, the wife's father, aninfluential politician, after much heartsearching,decides that public awareness of the dangers ofsyphilis is needed and that a certificate of freedomfrom syphilis must be obtained before marriage.

In his last remaining years Fournier producedseveral small books on the facts of life for the public,and these are much like others of their kind. Hisexcellent advice too often evoked a facetious responsefrom the press, as in the cartoon of 1908 whichshows him involving Cupid in a pre-marital examin-ation (Fig. 3, opposite).The reputation of the school of dermatology at

Paris in the late 19th century and the teachings ofFournier attracted dermato-venereologists from allover Eurcpe. Amongst others who attended wasEhlers from Denmark; in later life he stated howkind Fournier had been to him and how he hadbecome a confirmed francophile. John James Pringle(1855-1922) attributed his extraordinary commandof the French language to nightly attendance at theComedie Francaise for 6 months, whilst attendingthe clinics of Vidal and Fournier (Shelley andCrissey, 1953).Foumier was blessed with a happy stable home,

where dinner parties were held every Friday andSunday. Here students and friends could get toknow him and discuss matters of the day such as theDreyfus affair. The meal being finished, talk would

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Alfred Fournier, 1832-1914 235

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FIG. 3 Caricature of Fournier from the periodicalChanteclair (1908), vol. 1, no. 9, p. 2. By courtesyof the Wellcome Trustees

continue over coffee and afterwards Fournierplayed with his dog Dacia or at billiards. Then hewould retire to his study either to show post-graduate students his collection of early photographsof clinical conditions, or to write.Even at the peak of his reputation Fournier had to

sustain the taunts of the neurologists on the subjectof tabes and general paralysis: 'M'accuser de voir lasyphilis partout', souriait-il, 'moi qui passe mes

journees 'a retorquer l'erreur et i dire aux malades:'Mais non mon bon ami, vous n'avez pas la syphilis!'.

Perhaps the picture that Fournier gave of himselfto the world outside medicine is best described byDaudet, himself a tabetic who had fallen foul ofCharcot, in the Goncourt Journal for April 6, 1888:'Yesterday Leon Daudet described the domesticinterior of Fournier, the son-in-law and successor ofRicord, a house always full of gaiety where at partiesand dinners, they talk only about men's and women's

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natural parts and where at balls young girls can readtitles such as On Chancres on books left wide openon the tables (Becker and Philips, 1971).

Fournier died on December 25, 1914; many of hisideas on the control of syphilis had come to fruition,and they were taken up in Great Britain by the'Royal Commission on Venereal Diseases (1916)', andin Europe after the intemational congresses atBrussels in 1899 and 1902, for the 'Prophylaxis ofVenereal Diseases'.

ReferencesBECKER, C. J., and PHILIPS, E. (ed. and trans.) (1971)

'From the Goncourt Journal: Paris and the Arts1851-1896,' p. 251. Cornell University Press, Ithaca,U.S.A.

BIBLIOTHtQuE NATIONALE (1913) 'Catalogue general deslivres imprimes', vol. 54, p. 23. Paris

BRIEux, E. (1902) 'Les avaries'. Stock, ParisDARuER, J. (1915) Ann. Derm. Syph., 5e sir., 5, 513ERB, W. H. (1892) Samml. klin. Vortr., N.F., 53, 515FOURNIER, A. J. (1857) 'Hopital du Midi. Recherches sur

la contagion du chancre'. Delahaye, Paris(1860) 'De la contagion syphilitique'. Delahaye,

Paris- (1863) 'L'uremie'. These d'agregation. Faculty ofMedicine, University of Paris

- (1866) 'Note pour servir a l'histoire du rhumatismeuretral', lue a la Societie medicale des H'pitaux deParis, dans la seance du 23 Novembre, 1866. Malteste,Paris

- (1873) 'Clinique de l'Hopital de Lourcine. Legonssur la syphilis etudi&e plus particulierement chez lafemme'. Delahaye, Paris

(1875) Ann. Derm. Syph., ler ser., 7, 187, 401(1879) 'Le syphilis du cerveau. Leqons cliniques

recueillies par E. Brissaud'. Masson, Paris- (1882) 'De l'ataxie locomotrice d'origine syphilitique

(tabes specificus). Leqons cliniques professees al'Hopital Saint-Louis'. Masson, Paris.

- (1885) 'Leoons sur la periode praeataxique du tabesd'origine syphilitique, recueillies par W. Dubreuil'.Masson, Paris

- (1886) 'La syphilis hereditaire tardive', p. 63.Masson, Paris

- (1894) 'Les affections parasyphilitiques'. Rueff,Paris

(1894) 'Traitement de la syphilis'. Rueff, Paris(1897) 'Les chancres extra-genitaux. Legons re-

cueillies par Edmond Fournier'. Rueff, Paris(1899) 'Traite de la syphilis'. Rueff, Paris(1906) 'The Treatment and Prophylaxis of Syphilis'.

Trans. C. F. Marshall, translator's preface. Rebman,London

GOUGEROT, H. (1932) In 'Centenaire d'Alfred Fournier','Compte Rendu' p. 287. Peyronnet, Paris

- and BRODIER, L. (1932) 'L'H6pital Saint-Louis et laClinique d'Alfred Fournier', p. 29. Peyronnet, Paris

t".41:

t -0.4* ...-.,-.'-z ,.-

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Br J V

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236 British Journal of Venereal Diseases

GowERs, W. R. (1892) 'A Manual of Diseases of theNervous System', 2nd ed., vol. 1, p. 426. Churchill,London

HUTCHINSON, J. (1887) 'Syphilis'. Cassell, LondonMOTT, F. W. (1910) In 'A System of Syphilis', ed.

D'Arcy Power and J. Keogh Murphy, vol. 4, p. 486.Oxford University Press, London

NEIssER, A. L. S. (1879) Zbl. med. Wiss., 17, 497PROKSCH, J. X. (1889 and 1900) 'Die Litteratur uber die

venerischen Krankheiten'. Hanstein, Bonn

RIcoRD, P. (1838) 'Traite pratique des maladies veneri-ennes ou recherches critiques et experimentales surl'inoculation appliquee a l'tude de ces maladies,suivies d'un resume therapeutique et d'un formulairespecial.' De Just Rouvier and Le Bouvier, Paris

SHELLEY, W. B., and CRISSEY, J. T. (1953) 'Classics inClinical Dermatology'. Thomas, Springfield, Ill.

VIDAL, S. (1893) Ann. Derm. Syph., 3e ser., 4, 3WESTPHAL, C. F. 0. (1880) Zbl. klin. Med. (Bonn), 1, 12

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